Orthopedic Surgery in the Developing World: Workforce and Operative Volumes in Ghana Compared to Those in the United States

Abstract

Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country.
The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH).
There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH.
Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.

Full text

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World Journal of Surgery
Official Journal of the International
Society of Surgery/Société
Internationale de Chirurgie
ISSN 0364-2313
Volume 38
Number 4
World J Surg (2014) 38:849-857
DOI 10.1007/s00268-013-2314-0
Orthopedic Surgery in the Developing
World: Workforce and Operative Volumes
in Ghana Compared to Those in the United
States
Mark A.Brouillette, Scott P.Kaiser,
Peter Konadu, Raphael A.Kumah-
Ametepey, Alfred J.Aidoo & Richard
C.Coughlin

1 23
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Orthopedic Surgery in the Developing World: Workforce
and Operative Volumes in Ghana Compared to Those
in the United States
Mark A. Brouillette •Scott P. Kaiser •
Peter Konadu •Raphael A. Kumah-Ametepey •
Alfred J. Aidoo •Richard C. Coughlin
Published online: 12 November 2013
ÓSocie
´te
´Internationale de Chirurgie 2013
Abstract
Background Musculoskeletal disease is a growing burden
in low- and middle-income countries (LMICs), yet little
research exists to describe the problem. The purposes of
this study were to characterize orthopedic surgery in an
LMIC and compare the findings to those from a developed
country.
Methods The study location was the Komfo Anokye
Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic
surgeon, resident, and postgraduate training program
numbers were compared to analogous data from a devel-
oped nation, the United States. Annual surgical volumes
were compared to those at a level I trauma center in the
United States, the San Francisco General Hospital (SFGH).
Results There were 24 surgeons in Ghana compared to
23,956 in the United States. There were 7 orthopedic res-
idents and 1 residency program in Ghana versus 3,371
residents and 155 residencies in the United States. Annual
case volume was 2,161 at KATH and 2,132 at SFGH.
Trauma accounted for 95 % of operations at KATH com-
pared to 65 % at SFGH. The proportion of surgeries
devoted to severe fractures was 29 % at KATH compared
to 12 % at SFGH. Infections comprised 15 % of proce-
dures at KATH and 5 % at SFGH.
Conclusions Annual case volume at a referral hospital in
an LMIC is equivalent to that of a level I trauma center in
an industrialized country. Total case volume is similar, but
the LMIC institution manages a disproportionately large
number of trauma cases, severe fractures, and infections.
There is a large burden of orthopedic disease in the
developing nation, and there are too few providers and
training programs to address these conditions.
Introduction
Musculoskeletal disease is recognized globally as a major
cause of mortality, disability, chronic pain, and rising
health care costs [1,2]. In 2004, injuries alone accounted
for more than 3.9 million deaths and more than 138 million
disability-adjusted life years worldwide, 90 % of which
occurred in low- and middle-income countries (LMICs)
[3]. The burden of musculoskeletal disease is increasing in
LMICs because of falling communicable disease rates,
greater life expectancy, increasing obesity and sedentary
lifestyles, more road traffic crashes (RTCs), and a ‘‘brain
drain’’ of surgeons from developing nations [4–7].
Addressing this burden requires an understanding of the
distribution of disease and the availability of care in LMICs
[8]. Historically, epidemiologic research has focused on
infectious and nutritional illnesses rather than noncom-
municable and degenerative disease states, which are
increasing in number with the modernization of the
developing world [9]. As a result, orthopedic conditions
M. A. Brouillette
University of Colorado School of Medicine, Campus Box C290,
13001 East 17th Place, Building 500, 1st Floor East,
Aurora, CO 80045, USA
M. A. Brouillette (&)
2421 West 71st Street, Prairie Village, KS 66208, USA
e-mail: mark.brouillette@gmail.com
S. P. Kaiser R. C. Coughlin
Department of Orthopaedic Surgery, and Institute for Global
Orthopaedics and Traumatology, University of California
at San Francisco, 2550 23rd Street, Building 9, 2nd Floor,
San Francisco, CA 94110, USA
P. Konadu R. A. Kumah-Ametepey A. J. Aidoo
Department of Trauma and Orthopaedics, Komfo Anokye
Teaching Hospital, PO Box 1934, Kumasi, Ghana
123
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DOI 10.1007/s00268-013-2314-0
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were not a public health priority until the turn of the cen-
tury, and literature in this area has been slow to accumulate
[10]. The World Health Organization (WHO), World Bank,
and United Nations, as part of the Bone and Joint Decade
(2000–2010), emphasized that better musculoskeletal data
from LMICs is needed to inform health policy and to
measure the impact of interventions [11,12].
The purpose of this study was to establish a body of
orthopedic data in an LMIC where few previous records
exist. Specifically, we quantified the number of surgeons,
residents, and postgraduate training programs in an LMIC
and tallied annual surgical volumes at a referral hospital in
that country. Results were compared to analogous statistics
from a level I trauma center in a developed nation.
Materials and methods
Study location
The LMIC studied was Ghana, a nation in West Africa
with a population of 24,658,823 [13]. Ghana has a low-
middle-income economy with a per-capita gross national
income of $1,230 [14]. In 2011, the per-capita health care
expenditure in Ghana was $55 (or $114 using Purchasing
Power Parity analysis) compared to $7,164 per person in
the United States [15,16]. Ghana has 9.1 doctors per
10,000 citizens compared to 26.7 per 10,000 in the United
States [16].
The referral hospital studied was the Komfo Anokye
Teaching Hospital (KATH) in Kumasi, Ghana. KATH is a
1,200-bed institution with 2,700 staff. KATH is the pri-
mary teaching hospital for the Kwame Nkrumah University
of Science and Technology Medical School. It is the pri-
mary referral center for the northern two-thirds of Ghana.
The city of Kumasi has a population of 1.5 million and is
located in the Ashanti region. The population of the
Ashanti region is higher than four million, but the total
catchment for KATH includes more than ten million
individuals when referrals are considered [17].
The developed nation studied was the United States.
Surgical totals were obtained from a level I trauma center,
the San Francisco General Hospital (SFGH). SFGH is a
600-bed hospital and is the only level I trauma center for
the 1.5 million people living in San Francisco and northern
San Mateo County.
Protocol
The institutional review boards at KATH, the University of
California at San Francisco, and the University of Colorado
School of Medicine granted permission to conduct the
study. Data were collected in May 2010.
To describe the workforce in Ghana, a census of sur-
geons, residents, and postgraduate training programs was
obtained from the director of the Accident and Emergency
Center at KATH. To provide context, we compared the
findings to published reports from an industrialized nation,
the United States.
Annual surgical volumes at KATH were obtained from
operating theater logs. To provide context, similar totals
from SFGH were compiled and used for comparison. All
cases were classified according to diagnosis to determine
the rates of trauma, open fractures, and infections. Cases
were also classified by subspecialty and anatomic location.
Study variables
Trauma was defined as any surgery done for an acute
injury. Chronic conditions such carpal tunnel syndrome
and osteoarthritis were not included in this category. The
trauma was subclassified into categories of closed frac-
tures, open fractures, femoral fractures, and amputations.
Fracture totals excluded follow-up surgeries for hardware
removal and failed reductions. Severe fractures were
defined as open or femoral fractures.
Infections were subclassified into posttraumatic wound
infections, osteomyelitis, postoperative infections, and
‘‘other’’—a category that included septic arthritis, absces-
ses, and gangrenous disease.
Subspecialty surgeries were subclassified as arthro-
plasty, sports, foot and ankle, hand, spine, pediatric, and
oncology operations. Arthroplasty was defined as any
surgery in which a joint was reconstructed, regardless of
whether external hardware or exogenous tissue was uti-
lized. Sports surgery was defined as any operation
employing arthroscopy. Pediatric surgery was defined as
any surgery typically done by a pediatric orthopedist.
Surgeries by anatomic location were subclassified as
upper extremity, lower extremity, hip, pelvis, and spine
operations.
Statistical analysis
Our study is descriptive in design. Differences between
institutions in the proportion of total care devoted to major
categories of surgery were evaluated for significance using
two-sample ztests.
Of note, operating theater records at KATH were par-
tially incomplete. For example, 154 of 2,161 cases could
not be identified as either trauma or nontrauma. Because
incomplete entries were random, true category totals were
calculated within a known confidence interval (CI) using
proportional tests. As such, even though 1,908 operations
for trauma were known to have been done, we determined
there were actually 2,054 trauma surgeries performed
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(95 % CI 1,933–2,075). Tests of significance are unaf-
fected by this extrapolation. For clarity, CIs are not
reported. We did not apply the correction factor to gross
annual volume at KATH because we accounted for all
operations.
Results
Resources
There were 24 orthopedic surgeons in Ghana. In contrast,
there were 22,638 surgeons in the United States [18]. The
density of orthopedic surgeons in Ghana was 24 per
24,658,823 citizens or 0.10 surgeons per 100,000 people
[13]. The density of orthopedic surgeons in the United
States was 22,638 per 308,745,538 citizens or 7.33 sur-
geons per 100,000 individuals [19].
There were two postgraduate accrediting bodies in
Ghana, the West African College of Surgeons (WACS) and
the Ghana College of Surgeons (GCS). However, the
WACS was the only organization that offered licensure in
the orthopedic specialty. At the time of data collection,
there were seven active orthopedic residents in Ghana. In
comparison, there were 155 orthopedic residency programs
and 3,371 residents in the United States [20].
Surgeon, resident, and postgraduate training program
numbers are summarized in Table 1.
Surgical volumes
Annual case volume at KATH was 2,161, nearly equivalent
to the 2,132 surgeries performed at SFGH. The proportion
of care devoted to trauma at KATH was significantly
higher than at SFGH: 95 % (2,054 cases) compared to
65 % (1,376 cases), respectively (z=24.24, p\0.05).
There were 1,269 total fractures at KATH compared to
1,049 at SFGH. The amount of total care dedicated to
closed and open fractures at KATH was 47 % (1,023 cases)
and 11 % (246 cases) compared to 43 % (919 cases) and 6
(130 cases) at SFGH, respectively (z=2.79,6.10;
p\0.05). Femoral fractures comprised 18 % (389 cases)
of surgeries at KATH and 6 % (129 cases) at SFGH (11.83,
p\0.05). The number of amputations was 60 at KATH
compared to 51 at SFGH. Annual trauma volumes are
summarized in Fig. 1.
The proportion of cases done for infection at KATH was
significantly higher than at SFGH: 15 % (328 cases)
compared to 5 % (105 cases), respectively (z=11.13,
p\0.05). Infection cases at KATH were overwhelmingly
posttraumatic: 241 at KATH compared to 14 at SFGH.
There were 30 surgeries done for osteomyelitis at KATH
and 6 at SFGH. The number of de
´bridements for postop-
erative infections was 11 at KATH and 6 at SFGH. Annual
infection volumes are summarized in Fig. 2.
Table 1 Census of surgeons, residents, and postgraduate training
programs
Country Surgeons
(no.)
Residents
(no.)
Residency
programs
(no.)
Ghana 24 (0.10)
a
71
United States 22,638 (7.33)
a
3,713 155
a
Per 100,000 population
Fig. 1 Annual case volumes for trauma. KATH Komfo Anokye
Teaching Hospital, SFGH San Francisco General Hospital
Fig. 2 Annual case volumes for infections
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There were significantly fewer subspecialty surgeries
performed at KATH than at SFGH. Subspecialty proce-
dures accounted for 31 % of care (660 cases) at KATH and
61 % of care (1,311 cases) at SFGH (z=18.81, p\0.05).
Joint reconstruction constituted 10 cases at KATH com-
pared to 166 cases at SFGH. As sports surgeries were
defined as those employing arthroscopy, there were 0 cases
done at KATH and 145 cases done at SFGH. Foot and
ankle surgeries accounted for 346 cases at KATH and 620
cases at SFGH. The number of hand surgeries at KATH
was 134 compared to 252 at SFGH. The number of spine
surgeries at KATH was 6 compared to 83 at SFGH. At both
institutions, an unknown number of hand and spine sur-
geries were managed by plastic surgeons and neurosur-
geons, respectively. There were 64 pediatric cases done at
KATH and 23 at SFGH. For supracondylar fractures, there
were 43 surgeries done at KATH and 15 at SFGH. Galeazzi
and Monteggia fractures totaled 3 and 2 at KATH com-
pared to 3 and 1 at SFGH, respectively. Epiphysiodesis and
osteotomy accounted for 8 and 4 operations at KATH
versus 1 and 1 at SFGH, respectively. There were 4 ten-
otomies done at KATH and 1 at SFGH. There were 27
oncologic surgeries done at KATH compared to 22 at
SFGH. Annual subspecialty volumes are summarized in
Fig. 3.
At KATH, 99 % of surgeries (2,143 cases) were per-
formed on the extremities compared to 93 % (1,978 cases)
at SFGH. There were 555 upper extremity procedures done
at KATH and 491 at SFGH. The number of lower
extremity cases at KATH was 1,588 compared to 1,487 at
SFGH. Hip surgery cases totaled 189 at KATH and 202 at
SFGH. The number of pelvic surgeries done at KATH was
13 compared to 27 at SFGH. The number of procedures
done on the spine at KATH was 5 compared to 85 at
SFGH. Annual surgical volumes by anatomic location are
shown in Fig. 4.
A summary of the percentages of surgeries done for
trauma, severe fractures, infections, and subspecialty care
is presented in Fig. 5.
Discussion
Surgeons
There were three attending orthopedic surgeons at KATH,
meaning there is one surgeon per 1,027,451 citizens in
Ghana and one surgeon per 500,000 persons in Kumasi.
These densities are much less than the one surgeon per
13,638 individuals in the United States. Ghana has one-
third the density of doctors but one-seventieth the density
of orthopedic surgeons when compared to the United
States. This may suggest that specialists, in particular, are
in short supply in LMICs. Physician ‘‘brain drain’’ is a
primary cause of low provider numbers in the developing
world [6,7,21]. Brain-drain theory suggests that when
LMIC doctors train in developed nations they are drawn
away from their native countries by opportunities for
advanced training, employment, and political freedom [22].
At the time of our research, we learned that all orthopedists
at KATH had completed their postgraduate training abroad.
Many more who left Ghana to study orthopedics never
returned home to practice. These patterns suggest that brain
drain may be an important cause of low surgeon numbers
Fig. 3 Annual case volumes by subspecialty Fig. 4 Annual case volumes by anatomic location
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in Ghana. Sub-Saharan Africa has the highest rate of
physician emigration in the world, and Ghana has the
highest rate in the region, with 30 % of its doctors cur-
rently practicing in the United States, United Kingdom,
Canada, and Australia [7]. Within 3 years of graduation, as
many as two-thirds of Ghanaian physicians leave home to
practice abroad [23]. In Ghana, a culture of emigration
exists among faculty and students in which training outside
of the country is seen as a desirable achievement [24].
Numerous proposals to curb the flight of doctors from
LMICs have been made with an emphasis on the estab-
lishment of more in-country training programs [21,22,24–
27].
Training programs
The WACS and the CGS are accrediting postgraduate
training bodies in Ghana, but the WACS was the only
organization that offered specialty training in orthopedics.
Since 2005, the WACS has produced four orthopedic sur-
geons. At the time of data collection, there were seven
orthopedic residents in Ghana. These numbers are low
when compared to the 155 residency programs and 3,371
residents in the United States.
Presently, KATH leadership is in the process of estab-
lishing an accredited residency program through the GCS.
The creation of additional residency spots is likely to
improve physician retention in Ghana. Expanding post-
graduate training alone may not be a sufficient remedy for
brain drain, however. Even with the existing opportunity to
pursue a residency at KATH through the WACS, house
officers we spoke with avoided orthopedics because they
perceive that the training involves long hours, provides low
remuneration for challenging work, and offers an unreli-
able path to licensure. House officers pointed out that the
West African College does not have a fixed program
length, and promotion through the program is determined
by subjectively graded examinations that can prevent
matriculation. The proposed Ghana College residency has a
shorter program length. Unfortunately, house officers at
KATH worry that a GCS program at their institution may
have inadequate educational infrastructure in its develop-
ing stages. Although more postgraduate programs are
needed in LMICs, efforts to recruit and retain students are
necessary if these programs are to be successful.
Trauma
The proportion of care devoted to trauma at KATH was
significantly greater than at SFGH: 95 % compared to
65 %, respectively. In addition to the high volume of cases,
the overrepresentation of open fractures and femoral frac-
tures demonstrates that injuries are more severe at the
LMIC institution. Although pelvis and spine surgeries can
serve as surrogates for acuity, the low number of these
operations performed at KATH is a reflection of the facts
that pelvic fractures meeting surgical criteria by SFGH
standards are usually managed with extended period trac-
tion, and spine surgeries are done primarily by neurosur-
geons. Higher prehospital mortality in Ghana likely
contributes to the lower number of pelvis and spine sur-
geries as well.
A comparison of our data to those from a previous study
suggests that the volume of trauma surgery at KATH is
increasing. London et al. [28] reported that 2,022 trauma
patients were admitted to KATH between 1995 and 1996.
In all, 844 of these patients were operated on and 65 % of
the operations were orthopedic in nature. Assuming that
this is a linear trend, trauma cases at the LMIC tertiary
center are not only more prevalent and severe but are
increasing at a rate of 25 % per year. Although this is likely
due to a real increase in injuries, it also reflects a greater
surgical capacity at KATH resulting from addition of the
Accident and Emergency Center to the hospital in 2009.
It is important to note that our depiction of the burden of
trauma may be too modest. A previous study found that
51 % of trauma deaths occurred in a prehospital setting
[29]. Another study of mortuary records from KATH
showed that 80 % of injury-related deaths occurred outside
Fig. 5 Summary of operative volumes
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the hospital [30]. This means that a significant number of
patients die before reaching the operating room and are not
accounted for in theater records.
In the developing world, the high trauma burden is largely
a result of poor road traffic safety [5,31]. In Ghana, RTCs are
the leading cause of trauma-related morbidity and mortality
[30,32]. As LMICs have become increasingly motorized,
roads have not expanded fast enough to accommodate the
increase in traffic. Cars now compete with vulnerable
motorbikes and pedestrians for space on narrow streets.
Pedestrians alone account for 46 % of RTCs in Ghana [33].
A new study of femoral fractures at KATH found that 58 %
result from RTCs [34]. The greater volume and severity of
injuries we observed at KATH is likely due to the increasing
number of automobiles in Ghana in combination with
unprotected populations using the roadways.
The WHO has made recommendations to address the
surge of road traffic injuries in developing nations [35,36].
In Ghana, speed bumps and rumble strips installed between
Accra and Kumasi reduced crashes by 35 % and fatalities
by 55 % [37]. Televised campaigns for road traffic safety
have had some success in Ghana, especially in urban areas
[38]. In addition to preventive measures, trauma training
programs for nonphysician providers have been designed
for use in LMICs and have proven successful [39–46]. In
one program, Ghanaian commercial drivers were taught
basic first aid and reported applying these skills in the field
[47,48]. Although programs such as these are beneficial,
revised medical school and postgraduate curriculums are
likely to have the greatest impact on care [49]. The medical
school in Kumasi has developed a continuing medical
education course for rural general practitioners that focuses
on improving the management of injured patients [50]. In
urban centers such as Kumasi, training programs for spe-
cialists can bolster services for the severe injuries seen at
tertiary care institutions.
Infections
Our data show there are substantially more surgeries done
for infections at KATH than at SFGH: 328 cases annually
versus 105, respectively. Posttraumatic infections accoun-
ted for 241 operations at KATH compared to 14 at SFGH.
The reason for the greater number of trauma-related
infections at KATH is unclear. Possible factors contribut-
ing to this finding include differences between institutions
in timing and frequency of antibiotic administration, pro-
portion of open fractures, severity of fractures, degree of
contamination of open fractures, time to definitive wound
closure, postoperative dressing technique, nutritional sta-
tus, and rates of preexisting infection. Interestingly, time to
de
´bridement for open fractures has not been associated
with increased rates of infection [51].
In contrast to traumatic causes, KATH and SFGH had
similar postoperative infection rates: 0.51 % (11 cases)
versus 0.28 % (6 cases), respectively. Yet, surgeons at
KATH report that many surgery-related infections are not
recorded in the operative logs and the true infection rate is
probably much higher. Surgical-site infections are endemic
in the developing world and occur at an average rate of 5.6
per 100 procedures (compared to 2.6 per 100 surgeries in
the United States) [52]. In Ghana, the overall health care-
related infection rate has been estimated to be 6.7 %,
although the proportion of these resulting from surgery has
not been specified [53]. Future research is needed to
determine the true incidence of postoperative infection at
KATH. Several infection surveillance programs have been
introduced in LMICs in recent years [52]. Identifying
problem areas through surveillance can facilitate targeted
interventions for gaps in care.
Subspecialty care
We found that 31 % of surgeries at KATH and 61 % of
surgeries at SFGH fell under our definition of subspecialty
care. These findings demonstrate that subspecialty services
at the LMIC referral center are limited.
Joint reconstruction consisted of 8 cases at KATH
compared to 166 cases at SFGH, although the number of
hip operations were similar at the two institutions. These
results indicate there is an unmet demand for joint
replacement at least for the hip. Total hip arthroplasty and
knee replacement for osteoarthritis is a potentially cost-
effective intervention in developing countries if the
expertise to perform these operations is available [54].
Although KATH surgeons were trained in this technique,
implants for arthroplasty were unavailable. Disease
prevalence data and cost estimates are needed to deter-
mine if the implementation of arthroplastic services is
worthwhile.
Similarly, no arthroscopy was done at KATH. Although
KATH surgeons were trained in this technique, the nec-
essary equipment was lacking. The large trauma burden at
KATH indicates there is a substantial demand for arthro-
scopic care in Ghana. The diagnosis and treatment of
meniscal tears and degenerative joint disease with
arthroscopy can be cost-effective in LMICs if adequate
programs for rehabilitation are in place [55]. Rehabilitative
services are available at KATH and will play an important
role in patient outcomes if arthroscopic care is initiated.
Lower-extremity procedures were similar in number for
KATH and SFGH. They were done primarily for trauma.
The large number of lower-extremity cases at KATH
demonstrates an unmet demand for foot and ankle surgery.
Outside the theater, in the clinic, we observed a large
number of patients with clubfoot. More detailed outpatient
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records are needed to determine how many of these cases
require surgery.
With respect to hand surgery, although KATH performed
half as many operations as SFGH, it is difficult to draw con-
clusions about the provision of, or demand for, these services
because plastic surgeons were responsible for an unknown
number of cases at both institutions. The same is true for spine
surgeries. There were 4 spine operations performed at KATH
compared to 83 at SFGH. At KATH, neurosurgeons are
responsible for the majority of spine cases.
Pediatric surgery included operations for supracondylar
humeral fractures, Galeazzi and Monteggia fractures,
epiphysiodesis, osteotomy, and tenotomy. There were 64
pediatric surgeries performed at KATH and 23 at SFGH.
The SFGH total is an underestimate, however, because
there are two children’s hospitals that manage much of the
region’s care.
In all, 43 operations at KATH were done for supra-
condylar humeral fractures compared to 15 at SFGH.
Supracondylar fractures are the most common fractures in
the pediatric population [56]. They typically occur when
the elbow is hyperextended during a fall and can result in
neurovascular damage if not repaired promptly. A previous
study found that general orthopedic surgeons are able to
manage these injuries surgically as effectively as pediatric
subspecialists [57].
Epiphysiodesis and osteotomy were the next most
common pediatric operations. KATH performed eight and
four of these surgeries, respectively, and SFGH performed
one of each. These surgeries are typically done for angular
deformities of the lower extremities in children. In LMICs,
angular deformities are frequently the result of nutritional
rickets [58]. In equatorial countries, the vitamin D defi-
ciency that precipitates nutritional rickets is often due to
exclusive breast feeding and corn-based diets [56]. We
observed a large number of patients with angular defor-
mities in the outpatient clinic at KATH, but more complete
records are needed to quantify the demand for surgical
intervention.
The least common pediatric surgery was tenotomy, an
operation that is employed in the management of clubfoot.
Only four of these procedures were done at KATH com-
pared to two at SFGH. Clubfoot, or talipes equinovarus
(TEV), is the most common congenital malformation in
children and is the most prevalent orthopedic disease in
LMICs [59,60]. TEV has been a neglected disease in
developing countries because of the complex, multistage
surgeries required to correct these deformities. In recent
years, the management of early clubfoot has advanced
significantly in LMICs with the use of the Ponseti method
[61]. The Ponseti technique consists of nonsurgical
manipulations and casting that can be employed by non-
physicians with up to 98 % efficacy [56,62]. A program
employing the Ponseti method in Uganda has proven sus-
tainable, meaning this technique may be economical in
limited-resource settings [61]. At KATH, patients with
early TEV are managed by physical therapists using the
Ponseti method. Better outpatient data are needed to
determine the number of late TEV cases requiring surgery.
Deciding whether to provide subspecialty services can
be challenging for hospitals and health care planners.
Presently, there is little research describing the pros and
cons of diverting limited resources to the implementation
of these services in LMICs. Tibor and Hoenecke [55]
recognized this dilemma and devised a three-tiered
approach to prioritize subspecialty care. Tier one includes
basic trauma and infection care; tier two arthroscopy, soft-
tissue repair, and deformity correction; and tier three spine
surgery and arthroplasty. Higher tier procedures should be
implemented only when the provision of more essential
services in lower tiers is deemed adequate. Other important
considerations are the availability of subspecialty-trained
surgeons and technicians who can repair high-tech equip-
ment locally [63]. Further studies are needed at KATH to
determine if a basic level of care is being met and if
investment in subspecialty services is cost-effective.
Limitations
Our data describe orthopedic care in a single LMIC, so our
findings cannot be applied ubiquitously throughout the
developing world. For example, a tertiary care center in a
large city such as Kumasi is likely to see more RTCs and
severe injuries than a district hospital in a rural location.
For this reason, our conclusions are most applicable to
large referral hospitals in urban areas. Limited resources
are common to all LMICs, however, and are a primary
cause of physician brain drain, trauma, and inadequate
surgical services. As such, our conclusions on these topics
are likely to hold true for many developing nations.
Conclusions
The burden of bone and joint disease is increasing in
LMICs. To curb this trend, baseline epidemiologic and
treatment data are needed to inform effective health care
policy. Unfortunately, little such research exists. The pur-
pose of this study was to quantify providers, postgraduate
training programs and operative volumes in an LMIC and
to compare the findings to those from an industrialized
nation. Our results show that annual case volume at a large
referral hospital in an LMIC is equivalent to that at a level I
trauma center in a developed country. Although total case
volume is similar, the LMIC institution performs a
World J Surg (2014) 38:849–857 855
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disproportionately larger number of surgeries for traumas,
severe fractures, and infections. Despite a large burden of
disease in the LMIC, there are few providers and training
programs available to address these conditions.
Acknowledgments We thank Richard C. Fisher, MD, Chair of
Orthopaedics Overseas, for his assistance with the logistics of data
collection and for providing revisions to the manuscript.
Conflict of interest None.
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